MRI AND IV CONTRAST HISTORY AND SCREENING FORM

        

    MR#:

    Patient Name:
    Date:
    Sex:

    MF
    Height:
    Weight:
    DOB:
    Age:
    Referring Physician:
    Are you pregnant:
    YESNON/A
    Last Menstrual Period:
    Reason you are here today for an exam:
    Explain your medical problem in detail. (What happened? Where did it happen? How long have you had this problem?)

    Do you have pain?:
    YESNO
    Where:
    Have you had any surgeries in the area(s) that are being imaged today?
    YESNO
    Where:
    Have you taken any medication/sedation/alcohol today to help you relax for this procedure?
    YESNO
    If yes, please list:
    time taken:
    Have you had a previous exam related to this problem?
    YESNO
    If yes, explain:

    Do you have any of the following? (circle, if yes, please explain)
    YESNO
    Heart Surgery/Heart Valve
    YESNO
    Brain Surgery/Brain Aneurysm Clips
    YESNO
    Shunts/Stents/Intravascular Coil
    YESNO
    Eye Surgery/Implants
    YESNO
    Injury to eye involving metal or metal shavings
    YESNO
    Penile Prosthesis
    YESNO
    Orthopedic Pins/Rods/Screws/Plates/etc
    YESNO
    Neurostimulator/Biostimulator
    YESNO
    Radiation Therapy/Chemo Therapy
    YESNO
    History of Cancer or Tumor
    YESNO
    Surgery on spine (Neck or Back)
    YESNO
    Hearing Aids/Ear Surgery/Cochlear Implants
    YESNO
    Vascular Access Ports
    YESNO
    Metal/Mesh Implants/Wire Sutures/ Staples/Internal Electrodes
    YESNO
    Any type of Electrical/Magnetic/Mechanical Implants in your body
    YESNO
    Implanted Cardiac Pacemaker or Defibrillator
    YESNO
    Pacing Wires/Swan-Ganz Catheter
    YESNO
    Are you pregnant? Last Menstrual Period
    YESNO
    Tattoos/Permanent Make-up/ Body Piercings, Hair Extensions
    YESNO
    Dentures/Partials/Dental Implants
    YESNO
    Gunshot Wounds/ Shrapnel/ BB’s
    YESNO
    Seizures/Headaches/Dizziness
    YESNO
    Asthma/Allergic Respiratory Disease
    YESNO
    Blood disorder/ Sickle Cell Anemia
    YESNO
    Are you breast feeding at this time?
    YESNO
    Have you ever had a reaction to MRI contrast in the past?
    YESNO
    Stroke
    YESNO
    Kidney Disease
    YESNO
    Liver Disorder


    MRI AND IV CONTRAST HISTORY AND SCREENING FORM

        

    MR#:

    List any drug allergies:
    List all surgeries in your lifetime:
    List all medications you are currently taking:

    Acknowledgement: I have answered these questions to the best of my knowledge and understand the information presented to me.
    I have also informed the technologist that at this time I am pregnant OR NOT pregnant (circle).

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


    Patient/Parent/Legal Guardian Signature

    Technologist

    Date

    ********************************************* For Clinicians Use Only *******************************************

    BUN:

    Creatinine:

    or N/A Patient Pre-Exam Education Given:
    YESNO

    Clinician Providing Contrast Coverage:

    Contrast Administration:
    cc of
    with a


    (Needle Gauge & Type)
    @


    (Time)
    x


    (Number of Punctures)

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    By:


    Clinician Signature
    In


    Location of Site

    Lot #:Expiration Date:

    Contrast Reaction:

    YESNO

    Patient Discharge Instruction Given:

    YESNO

    Discharge Instruction for Contrast Extravasation Given:

    YESNON/A


    MRI AND IV CONTRAST HISTORY AND SCREENING FORM

        

    MR#:

    You have the right to be informed about the recommended diagnostic procedure to be used, so that you may make the decision whether or not to undergo this procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you can choose to give or withhold your consent to the procedure.

    If you are pregnant or think you may be pregnant, please inform center personnel at once. It is very important that you inform the technologist if you have a heart valve, a pacemaker, aneurysm clips, or other implanted metal or electrical devices.

    Your physician has requested a magnetic resonance imaging (MRI) examination to obtain additional information. MRI uses a magnetic field and radio waves to produce images of the body part being examined. MRI does not use x-rays or radiation and is painless. Some scanners may produce loud repetitive noises throughout the procedure therefore, headphones or earplugs will be provided.

    A contrast may be injected as part of your MRI to provide better images of the part of the body being examined.


    Potential Risks:
    The following complications are possible anytime an injection is given: potential for pain, bleeding, bruising or swelling at the injection site. MRI exams requiring contrast may result in: mild headache, nausea, itching or other vague symptoms for a short time after the injection.

    Additional allergic reactions in response to the contrast agent may include: hives, shortness of breath or difficulty in swallowing. There have been rare instances of death after the administration of the contrast agent. It is very important that you inform the technologist if you experience any of the conditions mentioned in this form.

    If you have previously had a reaction to a contrast injection such as hives, shortness of breath, any significant reaction requiring hospitalization, a history of asthma or other allergic conditions, any history of anemia, sickle cell anemia or kidney disorder; or if you are breastfeeding you must inform the technologist. The safety of contrast in children under 2 has not been established.

    The diagnostic test being performed was ordered by your physician based on your symptoms and condition. The benefits of this exam are to assist your physician with a diagnosis.


    I (WE) CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ IT, OR HAVE HAD IT READ TO ME (US), THAT THE BLANK SPACES HAVE BEEN FILLED IN AND THAT I (WE) UNDERSTAND ITS CONTENTS. I (WE) HAVE SUFFICIENT INFORMATION REGARDING THE PROCEDURE(S) AND THE RISKS AND HAZARDS INVOLVED.

    Patient Name Printed:

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    Patient Signature:

    Date:

    Time:

    :

    AM or PM

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    Witness Name Printed:

    Witness Signature:

    Date:

    Time:

    :

    AM or PM